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Culprit lesion location and outcome in patients with cardiogenic shock complicating myocardial infarction: a substudy of the IABP-SHOCK II-trial

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Abstract

Background

In myocardial infarction without cardiogenic shock (CS), the affected coronary vessel has significant influence on the final infarct size and patient prognosis. CS data on this relation are scarce. The objective of this study was to determine the prognostic relevance of the culprit lesion location in patients with CS complicating acute myocardial infarction.

Methods

In the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial patients with CS were randomized to therapy with intraaortic balloon pump or control. Additional CS patients not eligible for the randomized trial were included in a registry. We compared the location of the culprit lesions in these patients with regard to the affected coronary vessel [left main (LM), left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA)] and location within the vessel (proximal, mid or distal) regarding short- and long-term outcome.

Results

Of 758 patients, the majority had the culprit lesion in the LAD (44 %) compared to RCA (27 %), LCX (19 %) or LM (10 %). Proximal lesions were more frequent than mid or distal culprit lesions (60 vs. 27 vs. 13 %, p < 0.001). No differences were observed for mortality with respect to either culprit vessel (log-rank p value = 0.54). In contrast, a higher mortality was observed for patients with distal culprit lesions after 1 year (log-rank p value = 0.04). This difference persisted after multivariable adjustment (hazard ratio for distal lesions 1.40; 95 % confidential interval 1.03–1.90; p = 0.03).

Conclusion

For patients with CS complicating myocardial infarction, the culprit vessel seems to be unrelated with mortality whereas distal culprit lesions may have a worse outcome

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Abbreviations

AMI:

Acute myocardial infarction

CS:

Cardiogenic shock

DES:

Drug-eluting stent

LAD:

Left anterior descending coronary artery

LCX:

Left circumflex coronary artery

LM:

Left main coronary artery

PCI:

Percutaneous coronary intervention

RCA:

Right coronary artery

STEMI:

ST-segment-elevation myocardial infarction

TIMI:

Thrombolysis in myocardial infarction

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Acknowledgments

The IABP-SHOCK II-trial has been approved by the local ethics committee at each participating center and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All patients in the randomized study or their legally authorized representatives provided written informed consent.

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    Authors and Affiliations

    1. Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Heart Center Lübeck, University Hospital Schleswig–Holstein, Ratzeburger Allee 160, Lübeck, 23538, Germany

      Georg Fuernau, Steffen Desch, Ingo Eitel, Suzanne de Waha, Janine Pöss & Holger Thiele

    2. Department of Internal Medicine/Cardiology, University of Leipzig Heart Center, Leipzig, Germany

      Georg Fuernau, Karl Fengler & Gerhard Schuler

    3. German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany

      Georg Fuernau, Steffen Desch, Ingo Eitel, Suzanne de Waha, Janine Pöss & Holger Thiele

    4. Department of Cardiology, Bad Krozingen Heart Center, University of Freiburg, Bad Krozingen, Germany

      Franz-Josef Neumann

    5. Department of Internal Medicine I, Hospital Langen, Langen, Germany

      Hans-Georg Olbrich

    6. Department of Cardiology, German Heart Center Munich, Munich, Germany

      Antoinette de Waha

    7. Department of Cardiology/Angiology, Bad Segeberg Heart Center, Bad Segeberg, Germany

      Gert Richardt

    8. Department of Internal Medicine I, Klinikum am Gesundbrunnen, Heilbronn, Germany

      Marcus Hennersdorf

    9. Department of Internal Medicine B, University of Greifswald, Greifswald, Germany

      Klaus Empen

    10. Department of Cardiology/Angiology, Klinikum Links der Weser, Bremen, Germany

      Rainer Hambrecht

    11. Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Düsseldorf, Germany

      Christian Jung

    12. Department of Internal Medicine III, University of Homburg, Homburg/Saar, Germany

      Michael Böhm

    13. Clinic for Internal Medicine/Cardiology, University of Dresden-Heart Center, Dresden, Germany

      Ruth H. Strasser

    14. Institut für Herzinfarktforschung, Ludwigshafen, Germany

      Steffen Schneider, Taoufik Ouarrak & Uwe Zeymer

    15. Department of Internal Medicine III, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany

      Karl Werdan

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    1. Georg Fuernau
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    Funding

    Supported by grants from the German Research Foundation (Bonn, Germany), the German Heart Research Foundation (Frankfurt, Germany), the German Cardiac Society (Düsseldorf, Germany), Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (Berlin, Germany), the University of Leipzig-Heart Center (Leipzig, Germany) and by unrestricted grants from Maquet Cardiopulmonary (Rastatt, Germany) and Teleflex Medical (Wayne, PA, USA).

    Conflict of interest

    Dr. Thiele reports receiving consulting fees from Eli Lilly (Indianapolis, IN, USA) grant support on behalf of his institution from Eli Lilly and Terumo (Tokyo, Japan), and lecture fees from AstraZeneca (London, UK), Boehringer Ingelheim (Ingelheim, Germany), Daiichi Sankyo (Chuo, Japan), Eli Lilly, the Medicines Company (Leipzig, Germany), and Terumo; Dr. Zeymer reports serving on the board of Daiichi Sankyo and Eli Lilly and receiving consulting and lecture fees from Daiichi Sankyo, Eli Lilly and the Medicines Company; Dr. Richardt reports receiving lecture fees from Maquet Cardiovascular; Dr. Böhm received consulting fees from AstraZeneca, Bayer (Leverkusen, Germany), Boehringer Ingelheim, Daiichi Sankyo, Medtronic (Minneapolis, MN, USA), Merck (White House Station, NJ, USA), Novartis (Basel, Switzerland), Pfizer (New York City, NY, USA), Sanofi Aventis (Paris, France), and Servier (Neuilly-sur-Seine, France) and lecture fees from AstraZeneca, AWD.pharma Dresden (Radebeul, Germany), Bayer, Berlin-Chemie (Berlin, Germany), Boehringer Ingelheim, Daiichi Sankyo, Merck, Novartis, Pfizer, Sanofi Aventis, and Servier; Dr. Schneider reports serving on the ethics committee of Landesärztekammer Baden-Württemberg (Stuttgart, Germany), receiving payment for manuscript preparation from Biosense Webster (Diamond Bar, CA, USA), Grupo Ferrer (Barcelona, Spain), and Nycomed (Opfikon, Switzerland), and receiving money on behalf of the clinical research organization at his institution from Abbott Vascular (Chicago, IL, USA), AstraZeneca, Bayer, Biotronik (Berlin, Germany), Bristol-Myers Squibb (New York City, NY, USA), Boehringer Ingelheim, Cordis (Bridgewater Township, NJ, USA), Daiichi Sankyo, Diagenics (Luxembourg, Luxembourg), Enverdis (Jena, Germany), Eli Lilly, GlaxoSmithKline (Brentford, UK), Guidant (Natick, MA, USA), IKKF (Munich, Germany), Impulse Dynamics (Stuttgart, Germany), Medtronic, Merck, Novartis, Roche Diagnostics (Rotkreuz, Switzerland), Sanofi Aventis, Schering-Plough (Kenilworth, NJ, USA), Siemens (Munich, Germany), St. Jude Medical (Saint Paul, MN, USA), Takeda Pharma (Osaka, Japan), Tromssdorff (Alsdorf, Germany), and Vifor Pharma (Munich, Germany); and Dr. Werdan reports serving on the board of Biotest (Dreieich, Germany) and Servier, receiving grant support on behalf of his institution from Biotest and Servier, and receiving lecture fees from Biotest, Brahms (Henningsdorf, Germany), Maquet Cardiovascular, and Servier. Dr. Jung reports receiving grant support on behalf of his institution from Bayer Healthcare (Leverkusen, Germany), Actelion Pharmaceuticals (Freiburg, Germany) and Novartis (Basel, Switzerland), and lecture fees Bayer Healthcare (Leverkusen, Germany), Actelion Pharmaceuticals (Freiburg, Germany), Novartis (Basel, Switzerland), Boehringer Ingelheim (Ingelheim, Germany), Vifor Pharma (Glattbrugg, Switzerland), and Pfizer (Berlin, Germany). Dr. Pöss reports receiving lecture fees from AstraZeneca (London, UK). No other potential conflict of interest relevant to this article was reported.

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    G. Fuernau and K. Fengler contributed equally to the manuscript.

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    Fuernau, G., Fengler, K., Desch, S. et al. Culprit lesion location and outcome in patients with cardiogenic shock complicating myocardial infarction: a substudy of the IABP-SHOCK II-trial. Clin Res Cardiol 105, 1030–1041 (2016). https://doi.org/10.1007/s00392-016-1017-6

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